Because of the lawsuits, the “technical errors” such as getting the left foot amputated instead of the right, have been significantly reduced. However we continue to hear about the “thinking errors” that cause misdiagnosis and not treating the real illness. Sometimes these errors are small and can be corrected later but in many cases it can be too late by the time they are corrected.
The book “How Doctors Think” by Jerome Groopman is a good read to get into doctor’s mind and understand what role we as patients can play to reduce the probability of a thinking error. He has collected tons of real life stories of patients and doctors that were thinking errors. He uses his wrist illness as an example of how in spite of being a Doctor, he had difficulty in getting the correct diagnosis. He uses a lot of medical jargon, but I did not find it an impediment in understanding his view point. This blog post is my interpretation of the key points from the book.
Here are some of the factors that seem to contribute to these thinking errors:
- Time pressure on doctors to see most patients to maximize income
- Pressure not to stray from standardized procedures to avoid lawsuits, satisfy insurance companies and follow what they were taught in medical school
- Challenges in separating psychosomatic illnesses from physical illnesses
- Errors in analyzing the symptoms and test results to come to the appropriate conclusion
Coming up with an accurate diagnosis is very much like detective work, similar to what you see in shows like “Dr House”. In several situations, it requires out of the box thinking that takes time. In some cases, it requires a psychological skill of the Doctor to understand and interpret what the patient is saying, kind of like what you see in shows like “Lie to Me”.
Here are some of the typical cognitive biases that may lead to the thinking errors:
- Anchoring – Quickly and firmly latching on to a single possibility and ignoring other possibilities. If the patient’s blood sugar is high then focus on diabetes.
- Availability – tendency to pick relevant examples that quickly come to mind. If most recent patients are suffering from flu, then pick flu.
- Attribution – Base the decision on some personal attribute rather than evidence or symptom. If a patient is a complainer, then assume that it is all in his/her head.
- Confirmation bias – Selectively accepting or ignoring information to fit the diagnosis.
So what can we do as a patient?
- Learn more about your condition, diagnosis and treatment options so that you can understand the thinking the Doctor is going through and participate in the process.
- Ask the right constructive questions to prevent the pitfalls in Doctor’s thinking (This forces the Doctor to think and spend more time on your case and encourages him/her to think out of the box)
- Get second/third opinion or change the Doctor if he/she does not like to explain you or appreciate you participating in the diagnosis process.
- Dont give up – be persistent and hopeful
This book made me realize that Doctors are not much different from all of us. We make so many judgement calls in our personal and professional lives that are not black and white and are subject to errors. Our expectation is that since the judgement calls Doctors make deal with life and death, they need to be perfect all the time. However the complexity of the problem and the environmental factors do not always lend themselves well to a perfect decision every time. By being more proactive and participating in the process, we as patients can significantly improve the odds of making a perfect decision.